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Have you ever been in this situation?
Written by | Bao Zejun
Have you ever encountered a child who has been unconscious for a long time after anesthesia?
I came across it, and I'm still impressed, so I'm going to share it with you today.
The child is severely asphyxiated, has difficulty breathing, and is suspected of having a tracheal foreign body
The child, Hua Hua (pseudonym), a 5-year-old female, has a history of severe asphyxia, cough, hoarseness, dyspnea, cyanosis and wheezing. On examination, the child has stridor, wheezing, decreased breathing sound in the right lung, and suspicion of foreign body aspiration.
Because a foreign body in children is a serious, life-threatening condition, early recognition and emergency intervention are required. Children with tracheal foreign bodies usually have a history of asphyxia, which is typically associated with cough, wheezing, and decreased air intake, which occurs in about 40% of patients. Other symptoms include cyanosis, fever, and stridor.
In addition, it can manifest with symptoms of varying severity, including respiratory distress, chronic cough, atelectasis, recurrent pneumonia, and even death. On the other hand, it can be completely asymptomatic. Diagnosis requires a high index of suspicion and requires a detailed history, examination, and imaging.
Therefore, the medical team immediately performed a chest X-ray on Huahua, but no foreign body was found.
The doctor thought about it for a while, and the tracheal foreign body can be normal or abnormal on chest radiology examination, which is not the "gold standard" for tracheal foreign bodies. Therefore, bronchoscopy should be performed immediately in children with a suspicious history or symptoms, regardless of radiological findings.
Therefore, the medical team decided to perform bronchoscopy on Huahua.
Immediately after the administration of succinylcholine anesthesia, the child underwent exploratory bronchoscopy, and curiously, no foreign body was found during the examination, so what caused the child's asphyxia?
However, things developed rapidly, and before the doctor could think too much, the child had an emergency!
When the anesthesiologist started to wean the girl off the ventilator, the child's pupils constricted and he couldn't breathe on his own!
How to analyze the inability to breathe spontaneously after anesthesia?
Review the child's past medical history: no signs of liver damage, malnutrition, or any other serious illness, no history of drug use, then rule out the possibility of opioid and/or organophosphate chemical poisoning, and ask for a family history, and the result is that there is no family history of drug use or similar manifestations of anesthesia.
Thus, only one possibility remains, that is, apnea due to succinylcholine drugs, which occurs with a probability of about 1 in 1800 [1,2], of which approximately 65% is due to a decrease in succinylcholine hydrolysis caused by an aberrant butyrylcholinesterase (BChE) variant.
Decreased enzyme activity or reduced protein instability results in lower effective serum levels[3]. Anticholinesterase reduces enzyme activity, which leads to prolonged apnea after succinylcholine administration.
Because there is a high suspicion of an abnormal BChE variant, doctors choose to give intravenous atropine sulfate 1 mg and naloxone hydrochloride 0.4 mg.
After 5 minutes, Flowey began to breathe slowly on her own.
Later, laboratory tests showed that cholinesterase activity was very low. The child was treated with 150 ml of plasma and observed for 24 hours until he fully recovered.
Although normal enzymes in blood products, such as fresh frozen plasma or purified enzymes, replace the aberrant BChE variant and stabilize the disease, this treatment can lead to common transfusion risk-related complications [3]. Given the severity of succinylcholine apnea and the lack of a reversal agent, few other agents are available as ideal antidotes to apnea [4].
Therefore, when a delayed recovery after anesthesia is suspected to be due to pseudocholinesterase deficiency, the following measures must be strictly taken:
1. Continuous ventilatory support until recovery;
2. Enzyme levels must be determined for the patient and all family members;
3. Further exposure to suspected anesthetics must be avoided;
4. Medical staff must fully understand the patient's enzyme deficiency in order to formulate a rescue plan;
5. Patients and all family members undergo genetic screening for human BChE variants;
6. Remind patients to avoid exposure to anticholinesterase.
The child has no tracheal foreign body, what causes the asphyxia?
Back to the beginning of the case, after the doctor performed exploratory bronchoscopy, there was no obvious finding, so what caused the child to have difficulty breathing and severe asphyxia in the first place?
Long press to identify the QR code below or click at the end of the article to read the original text to view the answer~
Bibliography:
[1] I. Manoharan, S. Wieseler, P.G. Layer, O. et al, Naturally occurring mutation Leu307Pro of human butyrylcholinesterase in the Vysya community of India, Pharmacogenet. Genomics 16 (7) (2006) 461–468.
[2] H.W. Bauld, P.F. Gibson, P.J. Jebson, et al. Aetiology of prolonged apnoea after suxamethonium, Br. J. Anaesth. 46 (4) (1974) 273–281.
[3] F.K. Soliday, Y.P. Conley, R. Henker. Pseudocholinesterase deficiency: a comprehensive review of genetic, acquired, and drug influences, AANA J. 78 (4) (2010) 313–320.
[4]T.S. Mor, H. Soreq, Human cholinesterases from plants for detoxification, in: R.M. Goodman (Ed.), Encyclopedia of Plant and Crop Science, Marcel Dekker, Inc.,New York, 2004, pp. 564–567.
Editor in charge: Moon
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